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Abbasciano RG, Tomassini S, Roman MA, Rizzello A, Pathak S, Ramzi J, Lucarelli C, Layton G, Butt A, Lai F, Kumar T, Wozniak MJ, Murphy GJ. Effects of interventions targeting the systemic inflammatory response to cardiac surgery on clinical outcomes in adults. Cochrane Database Syst Rev 2023; 10:CD013584. [PMID: 37873947 PMCID: PMC10594589 DOI: 10.1002/14651858.cd013584.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND Organ injury is a common and severe complication of cardiac surgery that contributes to the majority of deaths. There are no effective treatment or prevention strategies. It has been suggested that innate immune system activation may have a causal role in organ injury. A wide range of organ protection interventions targeting the innate immune response have been evaluated in randomised controlled trials (RCTs) in adult cardiac surgery patients, with inconsistent results in terms of effectiveness. OBJECTIVES The aim of the review was to summarise the results of RCTs of organ protection interventions targeting the innate immune response in adult cardiac surgery. The review considered whether the interventions had a treatment effect on inflammation, important clinical outcomes, or both. SEARCH METHODS CENTRAL, MEDLINE, Embase, conference proceedings and two trial registers were searched on October 2022 together with reference checking to identify additional studies. SELECTION CRITERIA RCTs comparing organ protection interventions targeting the innate immune response versus placebo or no treatment in adult patients undergoing cardiac surgery where the treatment effect on innate immune activation and on clinical outcomes of interest were reported. DATA COLLECTION AND ANALYSIS Searches, study selection, quality assessment, and data extractions were performed independently by pairs of authors. The primary inflammation outcomes were peak IL-6 and IL-8 concentrations in blood post-surgery. The primary clinical outcome was in-hospital or 30-day mortality. Treatment effects were expressed as risk ratios (RR) and standardised mean difference (SMD) with 95% confidence intervals (CI). Meta-analyses were performed using random effects models, and heterogeneity was assessed using I2. MAIN RESULTS A total of 40,255 participants from 328 RCTs were included in the synthesis. The effects of treatments on IL-6 (SMD -0.77, 95% CI -0.97 to -0.58, I2 = 92%) and IL-8 (SMD -0.92, 95% CI -1.20 to -0.65, I2 = 91%) were unclear due to heterogeneity. Heterogeneity for inflammation outcomes persisted across multiple sensitivity and moderator analyses. The pooled treatment effect for in-hospital or 30-day mortality was RR 0.78, 95% CI 0.68 to 0.91, I2 = 0%, suggesting a significant clinical benefit. There was little or no treatment effect on mortality when analyses were restricted to studies at low risk of bias. Post hoc analyses failed to demonstrate consistent treatment effects on inflammation and clinical outcomes. Levels of certainty for pooled treatment effects on the primary outcomes were very low. AUTHORS' CONCLUSIONS A systematic review of RCTs of organ protection interventions targeting innate immune system activation did not resolve uncertainty as to the effectiveness of these treatments, or the role of innate immunity in organ injury following cardiac surgery.
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Affiliation(s)
| | | | - Marius A Roman
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Angelica Rizzello
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Suraj Pathak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Joussi Ramzi
- Leicester Medical School, University of Leicester, Leicester, UK
| | - Carla Lucarelli
- Department of Cardiac Surgery, University of Verona, Verona, Italy
| | - Georgia Layton
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ayesha Butt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Florence Lai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Marcin J Wozniak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Liu H, Li H, Han L, Zhang Y, Wu Y, Hong L, Yang J, Zhong J, Wang Y, Wu D, Fan G, Chen J, Zhang S, Peng X, Zeng Z, Tang Z, Lu Z, Sun L, Qian S, Shao Y, Zhang H. Inflammatory risk stratification individualizes anti-inflammatory pharmacotherapy for acute type A aortic dissection. Innovation (N Y) 2023; 4:100448. [PMID: 37333431 PMCID: PMC10276284 DOI: 10.1016/j.xinn.2023.100448] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 05/22/2023] [Indexed: 06/20/2023] Open
Abstract
The systemic benefits of anti-inflammatory pharmacotherapy vary across cardiovascular diseases in clinical practice. We aimed to evaluate the application of artificial intelligence to acute type A aortic dissection (ATAAD) patients to determine the optimal target population who would benefit from urinary trypsin inhibitor use (ulinastatin). Patient characteristics at admission in the Chinese multicenter 5A study database (2016-2022) were used to develop an inflammatory risk model to predict multiple organ dysfunction syndrome (MODS). The population (5,126 patients from 15 hospitals) was divided into a 60% sample for model derivation, with the remaining 40% used for model validation. Next, we trained an extreme gradient-boosting algorithm (XGBoost) to develop a parsimonious patient-level inflammatory risk model for predicting MODS. Finally, a top-six-feature tool consisting of estimated glomerular filtration rate, leukocyte count, platelet count, De Ritis ratio, hemoglobin, and albumin was built and showed adequate predictive performance regarding its discrimination, calibration, and clinical utility in derivation and validation cohorts. By individual risk probability and treatment effect, our analysis identified individuals with differential benefit from ulinastatin use (risk ratio [RR] for MODS of RR 0.802 [95% confidence interval (CI) 0.656, 0.981] for the predicted risk of 23.5%-41.6%; RR 1.196 [0.698-2.049] for the predicted risk of <23.5%; RR 0.922 [95% CI 0.816-1.042] for the predicted risk of >41.6%). By using artificial intelligence to define an individual's benefit based on the risk probability and treatment effect prediction, we found that individual differences in risk probability likely have important effects on ulinastatin treatment and outcome, which highlights the need for individualizing the selection of optimal anti-inflammatory treatment goals for ATAAD patients.
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Affiliation(s)
- Hong Liu
- Department of Cardiovascular Surgery, First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Haiyang Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Lu Han
- Department of Cardiovascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100043, China
| | - Yingyuan Zhang
- Department of Cardiovascular Surgery, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Ying Wu
- Department of Laboratory, First Affiliated Hospital of Shantou University Medical College, Shantou 515041, China
| | - Liang Hong
- Department of Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing 210012, China
| | - Jinong Yang
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, Qingdao 266003, China
| | - Jisheng Zhong
- Department of Cardiovascular Surgery, Xiamen Cardiovascular Hospital, Xiamen University, Xiamen 361004, China
| | - Yuqi Wang
- Department of Cardiovascular Surgery, Teda International Cardiovascular Hospital, Chinese Academy of Medical Sciences, Tianjin 300457, China
| | - Dongkai Wu
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Guoliang Fan
- Department of Cardiovascular Surgery, Shanghai East Hospital, Tongji University, Shanghai 200120, China
| | - Junquan Chen
- Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin Medical University, Tianjin 300222, China
| | - Shengqiang Zhang
- Department of Cardiovascular Surgery, First Affiliated Hospital of Bengbu Medical College, Bengbu 233099, China
| | - Xingxing Peng
- Department of Cardiovascular Surgery, First Affiliated Hospital of Guilin Medical University, Guilin 541001, China
| | - Zhihua Zeng
- Department of Cardiovascular Surgery, Second Affiliated Hospital of Nanchang University, Nanchang 330008, China
| | - Zhiwei Tang
- Department of Cardiovascular Surgery, First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Zhanjie Lu
- Jiangsu Provincial Center for Disease Control and Prevention, Public Health Research Institute of Jiangsu Province, Nanjing 210009, China
| | - Lizhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Sichong Qian
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Yongfeng Shao
- Department of Cardiovascular Surgery, First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Hongjia Zhang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Center, Beijing 100029, China
- Beijing Aortic Disease Center, Cardiovascular Surgery Center, Beijing 100029, China
- The Key Laboratory of Cardiovascular Remodeling-related Diseases, Ministry of Education, Beijing 100029, China
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Lv H, Li Q, Fei Y, Zhang P, Li L, Shi J, Lv H. Effects of Ulinastatin on Postoperative Renal Function in Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass: A Prospective Cohort Study with 10-Year Follow-Up. Cardiorenal Med 2023; 13:238-247. [PMID: 37315538 PMCID: PMC10664327 DOI: 10.1159/000531403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 02/14/2023] [Indexed: 06/16/2023] Open
Abstract
INTRODUCTION The present study aimed to explore the potential effect of ulinastatin on renal function and long-term survival in patients receiving cardiac surgery with cardiopulmonary bypass (CPB). METHODS This prospective cohort study was conducted at Fuwai Hospital, Beijing, China. Ulinastatin was applied after induction anesthesia. The primary outcome was the rate of new-onset postoperative acute kidney injury (AKI). Moreover, a 10-year follow-up was conducted until January 2021. RESULTS The rate of new-onset AKI was significantly lower in the ulinastatin group than in the control group (20.00 vs. 32.40%, p = 0.009). There was no significant difference in renal replacement therapy between the two groups (0.00 vs. 2.16%, p = 0.09). The postoperative plasma neutrophil gelatinase-associated lipocalin (pNGAL) and IL-6 levels were significantly lower in the ulinastatin group compared with the control group (pNGAL: p = 0.007; IL-6: p = 0.001). A significantly lower incidence of respiratory failure in the ulinastatin group compared with the control group (0.76 vs. 5.40%, p = 0.02). The nearly 10-year follow-up (median: 9.37, 95% confidence interval: 9.17-9.57) survival rates did not differ significantly between the two groups (p = 0.076). CONCLUSIONS Ulinastatin significantly reduced postoperative AKI and respiratory failure in patients receiving cardiac surgery with CPB. However, ulinastatin did not reduce intensive care unit and hospital stays, mortality, and long-term survival rate.
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Affiliation(s)
- Huanran Lv
- State Key Laboratory of Cardiovascular Disease, Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qian Li
- State Key Laboratory of Cardiovascular Disease, Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuda Fei
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, and Peking Union Medical College, Beijing, China
| | - Peng Zhang
- Department of Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihuan Li
- State Key Laboratory of Cardiovascular Disease, Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia Shi
- State Key Laboratory of Cardiovascular Disease, Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China,
| | - Hong Lv
- State Key Laboratory of Cardiovascular Disease, Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Horváth IL, Bunduc S, Fehérvári P, Váncsa S, Nagy R, Garmaa G, Kleiner D, Hegyi P, Erőss B, Csupor D. The combination of ulinastatin and somatostatin reduces complication rates in acute pancreatitis: a systematic review and meta-analysis of randomized controlled trials. Sci Rep 2022; 12:17979. [PMID: 36289288 PMCID: PMC9606296 DOI: 10.1038/s41598-022-22341-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 10/13/2022] [Indexed: 01/30/2023] Open
Abstract
Currently, there is no specific pharmaceutical agent for treating acute pancreatitis (AP). Somatostatin and its analogues have been used to prevent the autolysis of the pancreas in AP, however, their effectiveness has not been confirmed. This investigation aimed to examine the efficacy of ulinastatin, a protease inhibitor, combined with somatostatin analogues in the treatment of AP. We conducted a systematic database search in 4 databases to identify randomized controlled trials in which the efficacy of ulinastatin in combination with somatostatin analogue was compared to somatostatin analogue alone in patients with AP. Since the patient populations of analysed papers were slightly different, we used random effect models to pool odds ratios (OR) and mean differences (MD) and the corresponding 95% confidence intervals (CI). A total of 9 articles comprising 1037 patients were included in the meta-analysis. The combination therapy significantly reduced the complication rates for acute respiratory distress syndrome, acute kidney injury, and multiple organ dysfunction. Symptoms were relieved threefold with the combination therapy compared to somatostatin alone, and combination therapy significantly shortened the length of hospital stay. The decrease in mortality was not statistically significant..
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Affiliation(s)
- István László Horváth
- grid.11804.3c0000 0001 0942 9821Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1085 Budapest, Hungary ,University Pharmacy Department of Pharmacy Administration, Hőgyes Endre utca 7-9, 1092 Budapest, Hungary
| | - Stefania Bunduc
- grid.11804.3c0000 0001 0942 9821Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1085 Budapest, Hungary ,grid.11804.3c0000 0001 0942 9821Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Baross út 22-24, 1085 Budapest, Hungary ,grid.8194.40000 0000 9828 7548Carol Davila University of Medicine and Pharmacy, Dionisie Lupu Street 37, 020021 Bucharest, Romania ,grid.415180.90000 0004 0540 9980Fundeni Clinical Institute, Fundeni Street 258, 022328 Bucharest, Romania
| | - Péter Fehérvári
- grid.11804.3c0000 0001 0942 9821Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1085 Budapest, Hungary ,grid.483037.b0000 0001 2226 5083Budapest Department of Biomathematics and Informatics, University of Veterinary Medicine, István utca 2, 1078 Budapest, Hungary
| | - Szilárd Váncsa
- grid.11804.3c0000 0001 0942 9821Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1085 Budapest, Hungary ,grid.11804.3c0000 0001 0942 9821Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Baross út 22-24, 1085 Budapest, Hungary
| | - Rita Nagy
- grid.11804.3c0000 0001 0942 9821Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1085 Budapest, Hungary ,grid.9679.10000 0001 0663 9479Institute for Translational Medicine, Medical School, University of Pécs, Szigeti út 12, 7624 Pécs, Hungary ,grid.413987.00000 0004 0573 5145Heim Pál National Pediatric Institute, Üllői út 86, 1089 Budapest, Hungary
| | - Gantsetseg Garmaa
- grid.11804.3c0000 0001 0942 9821Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1085 Budapest, Hungary ,grid.11804.3c0000 0001 0942 9821Institute of Translational Medicine, Semmelweis University, Nagyvárad tér 4, 1089 Budapest, Hungary
| | - Dénes Kleiner
- grid.11804.3c0000 0001 0942 9821Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1085 Budapest, Hungary ,University Pharmacy Department of Pharmacy Administration, Hőgyes Endre utca 7-9, 1092 Budapest, Hungary
| | - Péter Hegyi
- grid.11804.3c0000 0001 0942 9821Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1085 Budapest, Hungary ,grid.9679.10000 0001 0663 9479Institute for Translational Medicine, Medical School, University of Pécs, Szigeti út 12, 7624 Pécs, Hungary ,grid.11804.3c0000 0001 0942 9821Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Baross út 22-24, 1085 Budapest, Hungary ,grid.9679.10000 0001 0663 9479János Szentágothai Research Center, University of Pécs, Szigeti út 12, 7624 Pécs, Hungary
| | - Bálint Erőss
- grid.11804.3c0000 0001 0942 9821Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1085 Budapest, Hungary ,grid.9679.10000 0001 0663 9479Institute for Translational Medicine, Medical School, University of Pécs, Szigeti út 12, 7624 Pécs, Hungary ,grid.11804.3c0000 0001 0942 9821Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Baross út 22-24, 1085 Budapest, Hungary ,grid.9679.10000 0001 0663 9479János Szentágothai Research Center, University of Pécs, Szigeti út 12, 7624 Pécs, Hungary
| | - Dezső Csupor
- grid.11804.3c0000 0001 0942 9821Centre for Translational Medicine, Semmelweis University, Üllői út 26, 1085 Budapest, Hungary ,grid.9679.10000 0001 0663 9479Institute for Translational Medicine, Medical School, University of Pécs, Szigeti út 12, 7624 Pécs, Hungary ,grid.9008.10000 0001 1016 9625Institute of Clinical Pharmacy, University of Szeged, Szikra utca 8, 6725 Szeged, Hungary
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Liu H, Qian SC, Shao YF, Li HY. Anti-Inflammatory Effect of Ulinastatin on the Association Between Inflammatory Phenotypes in Acute Type A Aortic Dissection. J Inflamm Res 2022; 15:3709-3718. [PMID: 35783246 PMCID: PMC9248951 DOI: 10.2147/jir.s369703] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/21/2022] [Indexed: 11/23/2022] Open
Abstract
Background Acute type A aortic dissection (ATAAD) is a heterogeneous systemic inflammatory response syndrome. Identification of distinct inflammatory phenotypes may allow more precise therapy and improved care. We aim to investigate whether distinct inflammatory subphenotypes exist in ATAAD patients and respond differently to pharmacotherapies. Methods Retrospective analysis of data sets was conducted from the Additive Anti-inflammatory Actions for Aortopathy & Arteriopathy (5A) III study. Inflammatory subphenotypes were derived among 2008 ATAAD patients who received surgical repair at 11 Chinese hospitals (2016–2020) using latent class analysis applied to 14 laboratory signatures within 6 hours of hospital admission. Outcomes included operative mortality (Society of Thoracic Surgeons definition), derived subphenotype frequency, and the potential consequences of phenotype frequency distributions on the treatment effects. Results The median (interquartile range) age of patients was 54 (45–62) years, and 1423 (70.9%) were male. A two-class (two subphenotype) model was an improvement over a one-class model (P<·001), with 1451 (72.3%) patients in the hypoinflammatory subphenotype group and 557 (27.7%) in the hyperinflammatory subphenotype group. Patients with the hyperinflammatory subphenotype had higher operative mortality (71 [12.7%] vs 127 [8.8%]; P=0·007) than did those with the hypoinflammatory subphenotype. Furthermore, the interaction between ulinastatin treatment and subphenotype is not significant for operative mortality (P=0.15) but for ventilator time (P=0·04). Conclusion Two subphenotypes of ATAAD were identified in the 5A cohort that correlated with clinical outcomes, with significant interaction effect between anti-inflammatory treatment and subphenotypes for ventilator time, suggesting these phenotypes may help in understanding heterogeneity of treatment effects. Trial Registration Clinical Trials. Gov: number NCT04918108.
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Affiliation(s)
- Hong Liu
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People’s Republic of China
| | - Si-chong Qian
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
| | - Yong-feng Shao
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People’s Republic of China
- Correspondence: Yong-feng Shao, Department of Cardiovascular Surgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, People’s Republic of China, Email
| | - Hai-yang Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China
- Hai-yang Li, Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, People’s Republic of China, Email
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Zhenyu H, Qiaoli Y, Guangxiang C, Maohua W. The effect of Ulinastatin on postoperative course in cardiopulmonary bypass patients in Asia: a meta-analysis of randomized controlled trials. J Cardiothorac Surg 2022; 17:66. [PMID: 35379277 PMCID: PMC8979706 DOI: 10.1186/s13019-022-01811-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 03/19/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES To evaluate the effect of urinary trypsin inhibitor (UTI) or Ulinastatin on postoperative course and clinical outcomes in patients with cardiopulmonary bypass. METHODS We searched PubMed, Embase, Web of Science, and Cochrane Library for the keywords UTI and Cardiopulmonary bypass (CPB). The primary outcome measure was the intensive care unit length of stay (ICU LOS), and results were stratified for relevant subgroups (dosage of UTI). The effects of UTI on mechanical ventilation duration (MVD), hospital LOS, renal failure incidence (RFI), and all-cause mortality were studied as secondary outcomes. RESULTS Twelve randomized controlled trials (enrolling 1620 patients) were evaluated. Eleven studies pooled for subgroup analysis showed that using UTI persistently or with a considerable amount would lead to a shorter ICU LOS (95% CI, - 0.69 to - 0.06; P = 0.0001). Ten studies showed that UTI could shorten MVD in patients (95% CI, - 1.505 to - 0.473; P < 0.0001). RFI generally showed a more favourable outcome with UTI treatment (95%CI, 0.18-1.17; P = 0.10). And the current evidence was insufficient to prove that UTI could reduce the hospital LOS (95% CI, - 0.22 to 0.16; P = 0.75) and the all-cause mortality rate (95% CI, 0.24-2.30; P = 0.60). CONCLUSIONS Various subsets of UTI treatment suggested that UTI could shorten ICU LOS, and it is associated with the dosage of UTI. Considering the substantial heterogeneity and lack of criteria for UTI dosage, more evidence is needed to establish a standard dosing guideline.
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Affiliation(s)
- Hu Zhenyu
- Department of Anesthesiology, Laboratory of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, People's Republic of China
| | - Yuan Qiaoli
- Department of Anesthesiology, Laboratory of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, People's Republic of China
| | - Chen Guangxiang
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou, People's Republic of China
| | - Wang Maohua
- Department of Anesthesiology, Laboratory of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, People's Republic of China.
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Peták F, Balogh ÁL, Hankovszky P, Fodor GH, Tolnai J, Südy R, Kovács BN, Molnár A, Babik B. Dopamine Reverses Lung Function Deterioration After Cardiopulmonary Bypass Without Affecting Gas Exchange. J Cardiothorac Vasc Anesth 2021; 36:1047-1055. [PMID: 34404593 DOI: 10.1053/j.jvca.2021.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/08/2021] [Accepted: 07/19/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the effects of dopamine on the adverse pulmonary changes after cardiopulmonary bypass. DESIGN A prospective, nonrandomized clinical investigation. SETTING A university hospital. PARTICIPANTS One hundred fifty-seven patients who underwent elective cardiac surgery that required cardiopulmonary bypass. INTERVENTIONS Fifty-two patients were administered intravenous infusion of dopamine (3 µg/kg/min) for five minutes after weaning from cardiopulmonary bypass; no intervention was applied in the other 105 patients. MEASUREMENTS AND MAIN RESULTS Measurements were performed under general anesthesia and mechanical ventilation before cardiopulmonary bypass, after cardiopulmonary bypass, and after the intervention. In each protocol stage, forced oscillatory lung impedance was measured to assess airway and tissue mechanical changes. Mainstream capnography was performed to assess ventilation- and/or perfusion-matching by calculating the normalized phase-3 slopes of the time and volumetric capnograms and the physiologic deadspace. Arterial and central venous blood samples were analyzed to characterize lung oxygenation and intrapulmonary shunt. After cardiopulmonary bypass, dopamineinduced marked improvements in airway resistance and tissue damping, with relatively small decreases in lung tissue elastance. These changes were associated with decreases in the normalized phase-3 slopes of the time and volumetric capnograms. The inotrope had no effect on physiologic deadspace, intrapulmonary shunt, or lung oxygenation. CONCLUSION Dopamine reversed the complex detrimental lung mechanical changes induced by cardiopulmonary bypass and alleviated ventilation heterogeneities without affecting the physiologic deadspace or intrapulmonary shunt. Therefore, dopamine has a potential benefit on the gas exchange abnormalities after weaning from cardiopulmonary bypass.
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Affiliation(s)
- Ferenc Peták
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary.
| | - Ádám L Balogh
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Péter Hankovszky
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Gergely H Fodor
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - József Tolnai
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Roberta Südy
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary; Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Barbara N Kovács
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary; Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Andrea Molnár
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary; Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Barna Babik
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
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Tascioglu D, Akkaya E, Genc S. The understanding of the immunopathology in COVID-19 infection. Scandinavian Journal of Clinical and Laboratory Investigation 2021; 81:255-263. [PMID: 34032527 DOI: 10.1080/00365513.2021.1892817] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Coronaviruses belonging to the Coronaviridae family are single-stranded RNA viruses. The entry of SARS-CoV-2 is accomplished via ACE-2 receptors. SARS-CoV-2 infection coactivates both innate and adaptive immune responses. Although SARS-CoV-2 stimulates antibody production with a typical pattern of IgM/IgG, cellular immunity is also impaired. In severe cases, low CD4 + and CD8 + T cell counts are associated with impaired immune functions, and high neutrophil/lymphocyte ratios accompanying low lymphocyte subsets have been demonstrated. Recently, high IFN -α/γ ratios with impaired T cell responses, and increased IL-1, IL-6, TNF-α, MCP-1, IP-10, IL-4, IL-10 have been reported in COVID-19 infection. Increased proinflammatory cytokines and chemokines in patients with severe COVID-19 may cause the suppression of CD4 + and CD8 + T cells and regulatory T cells, causing excessive inflammatory responses and fatal cytokine storm with tissue and organ damage. Consequently, novel therapeutics to be developed against host immune system, including blockade of cytokines (IL-6, IL-1, IFN) themselves, their receptors or signaling pathways- JAK inhibitors- could be effective as potential therapeutics.
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Affiliation(s)
- Didem Tascioglu
- Department of Infectious Disease and Clinical Microbiology, Liv Hospital, Istinye University, Esenyurt, Istanbul, Turkey
| | - Emre Akkaya
- Department of Biochemistry, Istanbul Faculty of Medicine, Istanbul University, Capa, Istanbul, Turkey
| | - Sema Genc
- Department of Biochemistry, Istanbul Faculty of Medicine, Istanbul University, Capa, Istanbul, Turkey
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"Cytokine storm", not only in COVID-19 patients. Mini-review. Immunol Lett 2020; 228:38-44. [PMID: 33007369 PMCID: PMC7524442 DOI: 10.1016/j.imlet.2020.09.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/10/2020] [Accepted: 09/22/2020] [Indexed: 01/09/2023]
Abstract
Cytokine storm is a form of uncontrolled systemic inflammatory reaction activated by a variety of factors and leading to a harmful homeostatic process, even to patient's death. Triggers that start the reaction are infection, systemic diseases and rarely anaphylaxis. Cytokine storm is frequently mentioned in connection to medical interventions such as transplantation or administration of drugs. Presented mini-review would like to show current possibilities how to fight or even stop such a life-threatening, immune-mediated process in order to save lives, not only in COVID-19 patients. Early identification of rising state and multilevel course of treatment is imperative. The most widely used molecule for systemic treatment remains tocilizumab. Except for anti IL-6 treatment, contemporary research opens the possibilities for combination of pharmaceutical, non-pharmaceutical and adjunctive treatment in a successful fight with consequences of cytokine storm. Further work is needed to discover the exact signaling pathways that lead to cytokine storm and to determine how these effector molecules and/or combination of processes can help to resolve this frequently fatal episode of inflammation. It is a huge need for all scientists and clinicians to establish a physiological rational for new therapeutic targets that might lead to more personalized medicine approaches.
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10
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Abstract
There is a large global unmet need for effective countermeasures to combat severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19). The development of novel antiviral drugs is expensive and too slow to meet the immediate need. The repurposing of drugs that are approved or are under advanced clinical investigation provides a cost- and time-effective therapeutic solution. This review summarizes the major repurposed approaches that have been proposed or are already being studied in clinical trials for COVID-19. Among these approaches are drugs that aim to reduce SARS-CoV-2 replication by targeting either viral enzymatic functions or cellular factors required for the viral life cycle. Drugs that modulate the host immune response to SARS-CoV-2 infection by boosting it to enhance viral clearance or by suppressing it to prevent excessive inflammation and tissue injury represent another category. Lastly, we discuss means to discover repurposed drugs and the ongoing challenges associated with the off-label use of existing drugs in the context of the COVID-19 outbreak.
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Affiliation(s)
- Sirle Saul
- Department of Medicine, Division of Infectious Diseases and
Geographic Medicine, and Department of Microbiology and Immunology,
Stanford University School of Medicine, Stanford
University, 300 Pasteur Drive, Lane Building, Rm
L127, Stanford, California 94305, United
States
| | - Shirit Einav
- Department of Medicine, Division of Infectious Diseases and
Geographic Medicine, and Department of Microbiology and Immunology,
Stanford University School of Medicine, Stanford
University, 300 Pasteur Drive, Lane Building, Rm
L127, Stanford, California 94305, United
States
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11
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Zhao M. Cytokine storm and immunomodulatory therapy in COVID-19: Role of chloroquine and anti-IL-6 monoclonal antibodies. Int J Antimicrob Agents 2020; 55:105982. [PMID: 32305588 PMCID: PMC7161506 DOI: 10.1016/j.ijantimicag.2020.105982] [Citation(s) in RCA: 173] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/05/2020] [Accepted: 04/07/2020] [Indexed: 12/16/2022]
Abstract
•Discussion of the role of immunomodulatory agents to reduce the cytokine storm in severe cases of COVID-19. •Potential immunomodulatory agents currently used in the treatment of COVID-19 (chloroquine, hydroxychloroquine and tocilizumab) are discussed. •Other immunomodulatory agents with good safety profiles may be considered for use in combination with antiviral drugs for the treatment of severe or critical cases of COVID-19.
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Affiliation(s)
- Ming Zhao
- Department of Pharmacy, Beijing Hospital, National Centre of Gerontology, Beijing, P.R. China; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, P.R. China.
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